The results of this service evaluation suggest a low level of adherence to prescribing guidelines in the treatment of community acquired pneumonia. Adherence rates were similar to the 16.1% demonstrated in an Australian study of 193 patients admitted with CAP [8], but fell well short of the 52.3% compliance found in a similarly sized study in a French teaching hospital [9]. In an Irish setting, an audit of antimicrobial prescribing in 69 hospitalised patients with CAP showed 21.6% compliance with guidelines [10].
We did, however, find that the choice of antibiotic was frequently deemed appropriate in the clinical context. This highlights the importance of physicians’ clinical judgment in conjunction with the CURB-65 scoring system and hospital prescribing guidelines, and it is important to note that co-morbid conditions, failure of community-prescribed antibiotic therapy, and social circumstances are not represented in the CURB-65 scoring system [11].
That patients with a higher CURB-65 score were more likely to receive antibiotics in keeping with hospital guidelines suggests that NCHDs are more familiar with hospital guidelines for higher scoring patients.
This may also reflect a hesitancy among NCHDs in the use of oral agents or monotherapy in patients admitted with CAP and a low CURB-65 score.
Specialist review by an ID or respiratory specialist increased rates of appropriate antimicrobial prescribing, but the impact on appropriate treatment duration was not statistically significant. This may have been due to the study size, or could also have reflected uncertainty among physicians regarding the optimal duration of antibiotics in patients with a diagnosis of Covid-19 during the initial outbreak in Ireland. Furthermore, while a specialist may give their input in the form of advice and recommendations, it is the responsibility of the primary team to act upon this advice where deemed appropriate.
The benefit of specialist input regarding antimicrobial prescribing is in keeping with prior studies that demonstrate the positive impact of ID specialist input on antibiotic prescribing practices. A major review article found that ID specialist input improve prescribing practices, while also reducing length of stay and mortality [4].
There are no large-scale analysis of the specific impact of ID or respiratory input on prescribing practices in CAP.
Only 56.6% of patients completed an appropriate duration of therapy, and the average duration of therapy specifically targeting CAP was 9.8 days. This was consistent with a nationwide study performed in the USA, which found a median total length of therapy of just under 10 days [12].
The figure of 9.8 days was higher than the 8.6 day average duration in the November-January cohort. This might suggest uncertainty regarding the appropriate treatment duration in Covid-19 positive patients, and may also reflect the fact that the medical teams within the hospital switched to a ward-based system of care during the initial Covid-19 outbreak, with patients more frequently moving wards depending on Covid-19 status, availability of isolation rooms, and oxygen requirements. This may have impacted on continuity of care and thus resulted in certain medications being continued for longer than was indicated. While advice regarding the appropriate duration of therapy may have been provided by the ID or respiratory specialist, the ultimate decision on duration of treatment was made by the primary team.
Limitations of this study include the relatively small sample size and the potential influence of seasonal variation. Furthermore, a lack of data regarding the optimal treatment of Covid-19 at a time of great concern and uncertainty within the medical community may have influenced antibiotic prescribing practices among general medical physicians and ID/respiratory specialists alike. Finally, the difference between average lengths of stay in each cohort was statistically significant. This may reflect increased uncertainty regarding appropriate duration of therapy, duration of isolation, and availability of facilities for patients to self-isolate upon discharge with a diagnosis of Covid-19. Ultimately, a large-scale study is required to analyse the impact of Covid-19 on prescribing practices in CAP, and a repeat study outside of the pandemic setting would be valuable for comparison.
In summary, this service evaluation demonstrates the value of ID and respiratory specialist input in prescribing practices in CAP. Overall, compliance with prescribing guidelines is low, but the choice of antibiotic can often be deemed appropriate in the clinical context.
Our findings may reflect a lack of familiarity or a lack of confidence in following prescribing guidelines (particularly in prescribing oral antibiotics) in patients requiring hospitalisation, especially when treating patients with a low CURB-65 score. This suggests a need for increased awareness and education of prescribing guidelines, particularly among NCHDs, who are commonly the ones initiating therapy at the time of hospital admission.